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2.9 Antiplatelet drugs

Acute coronary syndrome - prasugrel - NICE TAG TA182

1.1 Prasugrel in combination with aspirin is recommended as an option for preventing atherothrombotic events in people with acute coronary syndromes having percutaneous coronary intervention, only when:

  • immediate primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction is necessary or

  • stent thrombosis has occurred during clopidogrel treatment or

  • the patient has diabetes mellitus.

1.2 People currently receiving prasugrel for treatment of acute coronary syndromes whose circumstances do not meet the criteria in 1.1 should have the option to continue therapy until they and their clinicians consider it appropriate to stop.

https://www.nice.org.uk/guidance/TA182

Vascular disease - clopidogrel and dipyridamole - NICE TAG TA210

This guidance applies to people who have had an occlusive vascular event, or who have established peripheral arterial disease. For people who have had a myocardial infarction, this guidance follows on from the recommendations for clopidogrel in combination with low-dose aspirin in NICE clinical guideline 48 and NICE clinical guideline 94. This guidance does not apply to people who have had, or are at risk of, a stroke associated with atrial fibrillation, or who need treatment to prevent occlusive events after coronary revascularisation or carotid artery procedures.

1.1 Clopidogrel is recommended as an option to prevent occlusive vascular events:

  • for people who have had an ischaemic stroke or who have peripheral arterial disease or multivascular disease or

  • for people who have had a myocardial infarction only if aspirin is contraindicated or not tolerated.

1.2 Modified-release dipyridamole in combination with aspirin is recommended as an option to prevent occlusive vascular events:

  • for people who have had a transient ischaemic attack or

  • for people who have had an ischaemic stroke only if clopidogrel is contraindicated or not tolerated.

1.3 Modified-release dipyridamole alone is recommended as an option to prevent occlusive vascular events:

  • for people who have had an ischaemic stroke only if aspirin and clopidogrel are contraindicated or not tolerated or

  • for people who have had a transient ischaemic attack only if aspirin is contraindicated or not tolerated.

1.4 Treatment with clopidogrel to prevent occlusive vascular events should be started with the least costly licensed preparation.

1.5 People currently receiving clopidogrel or modified-release dipyridamole either with or without aspirin outside the criteria in 1.1, 1.2 and 1.3 should have the option to continue treatment until they and their clinicians consider it appropriate to stop.

https://www.nice.org.uk/guidance/TA210

Acute coronary syndromes - ticagrelor - NICE TAG TA236

1.1 Ticagrelor in combination with low-dose aspirin is recommended for up to 12 months as a treatment option in adults with acute coronary syndromes (ACS) that is, people:

  • with ST-segment-elevation myocardial infarction (STEMI) – defined as ST elevation or new left bundle branch block on electrocardiogram – that cardiologists intend to treat with primary percutaneous coronary intervention (PCI) or

  • with non-ST-segment-elevation myocardial infarction (NSTEMI) or

  • admitted to hospital with unstable angina – defined as ST or T wave changes on electrocardiogram suggestive of ischaemia plus one of the characteristics defined in section 1.2. Before ticagrelor is continued beyond the initial treatment, the diagnosis of unstable angina should first be confirmed, ideally by a cardiologist.

1.2 For the purposes of this guidance, characteristics to be used in defining treatment with ticagrelor for unstable angina are: age 60 years or older; previous myocardial infarction or previous coronary artery bypass grafting (CABG); coronary artery disease with stenosis of 50% or more in at least two vessels; previous ischaemic stroke; previous transient ischaemic attack, carotid stenosis of at least 50%, or cerebral revascularisation; diabetes mellitus; peripheral arterial disease; or chronic renal dysfunction, defined as a creatinine clearance of less than 60 ml per minute per 1.73 m2 of body-surface area.

https://www.nice.org.uk/guidance/TA236

Prasugrel with percutaneous coronary intervention for treating acute coronary syndromes (review of technology appraisal guidance 182) - NICE TAG TA317

1.1 Prasugrel 10 mg in combination with aspirin is recommended as an option within its marketing authorisation, that is, for preventing atherothrombotic events in adults with acute coronary syndrome (unstable angina [UA], non-ST segment elevation myocardial infarction [NSTEMI] or ST segment elevation myocardial infarction [STEMI]) having primary or delayed percutaneous coronary intervention.

http://www.nice.org.uk/Guidance/TA317

Cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti‑platelet therapy (terminated appraisal) - NICE TAG TA351

NICE is unable to make a recommendation about the use in the NHS of cangrelor for reducing atherothrombotic events in people undergoing percutaneous coronary intervention or awaiting surgery requiring interruption of anti-platelet therapy because no evidence submission was received from The Medicines Company.

http://www.nice.org.uk/guidance/ta351

Ticagrelor for preventing atherothrombotic events after myocardial infarction - NICE TAG TA420

1.1 Ticagrelor, in combination with aspirin, is recommended within its marketing authorisation as an option for preventing atherothrombotic events in adults who had a myocardial infarction and who are at high risk of a further event.

Treatment should be stopped when clinically indicated or at a maximum of 3 years.

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